A systematic review and thematic synthesis of qualitative studies exploring GPs' and nurses' perspectives on discussing weight with patients with overweight and obesity in primary care

Summary Guidelines and evidence suggest primary care clinicians should give opportunistic interventions to motivate weight loss, but these rarely occur in practice. We sought to examine why by systematically reviewing qualitative research examining general practitioners' (‘GPs’) and nurses' views of discussing weight with patients. We systematically searched English language publications (1945‐2018) to identify qualitative interview and focus group studies. Thematic methods were used to synthesise the findings from these papers. We synthesised the studies by identifying second‐order themes (explanations offered by the original researchers) and third‐order constructs (new explanations which went beyond those in the original publications). Quality assessment using the Joanna Briggs checklist was undertaken. We identified 29 studies (>601 GPs, nurses and GP trainees) reporting views on discussing weight with patients. Key second‐order themes were lack of confidence in treatments and patients' ability to make changes, stigma, interactional difficulty of discussing the topic and a belief of a wider societal responsibility needed to deal with patients with overweight and obesity. The third‐order analytical theme was that discussions about weight were not a priority, and other behavioural interventions, including those relating to smoking, often took precedent. GPs and nurses reported that noting body mass index measurements at every consultation alongside a framework to deliver interventions would likely increase the frequency and perceived efficacy of behavioural weight interventions. GPs and nurses acknowledge the importance of obesity as a health issue, but this is insufficient, particularly amongst GPs, for them to construe this as a medical problem to address with patients in consultations. Strategies to implement clinical guidelines need to make tackling obesity a clinical priority. Training to overcome interactional difficulties, regular weighing of patients and changing expectations and understanding of weight loss interventions are also probably required.


| INTRODUCTION
Several national guidelines recommend that primary care physicians should identify patients with obesity and provide treatment options, including brief opportunistic behavioural interventions. [1][2][3] A recent trial showed direct evidence for the effectiveness and acceptability of a primary care opportunistic 4 intervention which offered referral to a behavioural weight-management programme. 5 If implemented at a population level, this could reduce the projected annual incidence of heart disease, hypertension and diabetes by 22%, 23% and 17% by 2035. 5 Despite such evidence and guidelines, primary care weight management interventions are rare and declining. In the United Kingdom, for example, only 3% of people with obesity are referred by general practitioners (GPs) for weight loss support despite obesity prevalence being 27% and the average person visiting their GP six times per year. 6,7 Survey data have shown that weight management counselling of patients with obesity visiting their GP in US primary care declined from 33% in 2008 to 2009 to 21% in 2012 to 2013 and the reported prevalence of obesity in primary care records is considerably underestimated. 8 In the United Kingdom, surveys suggest that a minority of patients with overweight (17%) or obesity (42%) recalled ever having been offered weight loss advice by primary care nurses and GPs. 9 Surveys suggest that GPs believe that obesity does not belong in the medical domain, 10 whilst qualitative evidence from interviews suggest that weight loss discussions are an inappropriate use of their time and also worry about damaging the relationship with the patient. 11 Conversely, patients with overweight report being open to receiving GP advice on weight loss, with less than 1% describing it as inappropriate. 5,12 A systematic review on this topic 13 uncovered largely quantitative studies, (11/13) (studies were surveys and questionnaires), describing GPs' and nurses' views, finding that weight is awkward to discuss. There have been two 14,15 exclusively qualitative reviews investigating this topic. One 14 focused on the issue of stigma, but because of the narrow search criteria (studies had to mention stigma), it did not examine other barriers to conversations (such as time, lack of skills and confidence) nor did it explore clinical implications-for example, it did not examine attitudes towards guidelines. This criterion also limited the breadth and number of studies, including two studies of GPs and five studies of primary care nurses. The other qualitative review by Dewhurst et al. 15 provided insights into GPs' reported views and experiences but missed key studies related to physicians' in training, nurses' experiences and studies related to communication with patients, perhaps because the electronic search was too narrow. We therefore aimed to provide a comprehensive overview of GPs' and nurses' views of treating obesity in primary care using broader selection criteria than either of the other published reviews. Effective strategies to implement obesity guidelines need to understand how GPs and nurses view treating obesity if they are to succeed. We undertook a systematic synthesis of research with GPs and nurses to understand (i) why conversations with patients with overweight are infrequent and (ii) to identify potential mechanisms to increase the frequency of discussions in practice.

| Terminology
This study included papers from many different countries with different terms for family doctors, GPs, family nurses and practice nurses.
For consistency and clarity, we will call all types of family practitioners (GPs) and will call all primary care nurses, practice nurses and family nurses (nurses).

| Search strategy
The search criteria used terms relating to (1) primary care, (2) overweight and obesity and (3) discussions and communications about weight (example of search code displayed in Box 1). During the development of the search, we trialled wider search terms, which included 'cultural influences' affecting the discussion of weight, but these did not yield additional studies. We also used forward and backward citation searches, which yielded two additional studies.

| Information sources
Searches were carried out using an emergent rather than an exhaustive strategy, following an approach used to address other complex public health questions. 16 The reviewers identified relevant search terms, which were then further explored by an information specialist Box 1: Example of search code As an example, the following is the code used for PubMed: Search (((((("Health Communication"[Mesh]) OR "Professional-Patient Relations"[Mesh])) OR (talk* OR communicat* OR conversation* OR "raise the issue" OR "raising the issue" OR "raise the topic" OR "raising the topic" OR "broach the topic" OR "broaching the topic" OR "raise the subject" OR "raising the subject" OR "broach the subject" OR "broaching the subject" OR counsel* OR advice OR advising))) AND (((overweight OR obes* OR weight 1 OR "lose weight" OR "losing weight" OR "weight loss")) OR ((("Overweight" [Mesh] OR "Weight Loss"[Mesh:NoExp])) OR (overweight OR obes* OR weight 1 OR "lose weight" OR "losing weight" OR "weight loss")))) AND (((("General Practice" [

| Study selection
We included studies which were carried out in primary care, reported the perspectives of primary care staff in discussing overweight and obesity with adults (18+ years) who were overweight and included qualitative studies based on interviews or focus groups in which GPs and nurses reported their views about discussing overweight.
We excluded studies carried out exclusively in specialist health care, studies that reported GPs' and nurses' views of discussing excess weight with children, parents or pregnant women, studies exclusively about the attitudes of patients rather than health-care professionals, quantitative studies involving surveys or questionnaires and discussions exclusively concerning underweight or anorexia. Abstracts were excluded because they are too short for useful thematic analysis. Books and dissertations were excluded for practical reasons.
Title and abstract screening was conducted by two independent reviewers (WW and CA) using Covidence. In the event of disagreement, the article proceeded to the next phase. 17 Full text screening was done by WW, and two 10% samples were checked by other authors.

| Quality assessment and risk of bias
We appraised data quality using the Joanna Briggs checklist, which has been recommended as the most coherent and comprehensive tool to capture study quality. 18 Based on the results of this checklist, we assessed whether the 'higher-quality' studies contributed richer data to the thematic analysis We found that there was no such relationship and therefore included all papers. 17

| Methods for data extraction and a thematic synthesis
We included both the results and interpretations sections of papers, following the approach of Thomas and Harden. 19,20 Thematic synthesis involved three overlapping stages: (i) free line-by-line coding of the all findings and discussion sections of the primary studies using NVivo software (version 11) 21 ; (ii) the consolidation of these 'free codes' into related areas to develop overarching 'descriptive themes' which were completed by organising the results into a mind-map (WW, CA and BN) 22 ; (iii) and the development of analytical themes, which directly addressed the aims of the review. In metaethnography, the equivalent to this last stage of 'analytical themes' is 'third-order interpretations.' 23

| Protocol and registration
We wrote a protocol which was supplied to the editor of the journal.

| RESULTS
The search identified 1,525 nonduplicated studies, of which 29 were included for final analysis after a screening process displayed in Figure 1. Qualitative data from the included studies provided data for 601 GPs and nurses. The earliest paper was published in 2001.

| Study quality and risk of bias
There were some quality issues. Some studies did not report ethical approval 11,24 ; authors drew conclusions that did not flow from the data 25 or did not discuss reflexivity. 26,27 Recruitment to the study group was sometimes self-selected from a subgroup with training in weight management [28][29][30] or recruitment was incentivised by offering educational obesity treatment training, 27 which perhaps meant that clinicians with greater interest were recruited. Table 1 demonstrates the similarity of findings across different countries, between 2001 and 2017. The themes are the interactional difficulty of raising the topic in the consultation, a lack of confidence in treatments, a lack of confidence in patients to make changes, lack of knowledge and skills, insufficient time or resources, the suggestion that weight loss is not their clinical responsibility and stigma. Table 1 Box 2: Sources and coverage dates also illustrates that there has been little change in the number or types of themes discussed since 2001. In some instances in the following sections, descriptive themes are discussed together to save space.

| The awkward nature of weight discussions
The interactional delicacy of the topics was a key theme addressed in 22 of 29 papers. It covered a number of subthemes described as follows.

Word choice
Clinicians reported word choice as a barrier, with concern particularly that their patients might be offended and rapport damaged if terms such as 'overweight' or 'obesity' were used. 25,27,36,44,45,47,48,50 This experience was similar across many different countries in both public and private settings: a UK GP reported that using these terms was not 'very PC (politically correct)' and could cause patients to get 'very hurt' 47 ; another Singapore GP in a private practice reported patients being offended by such terms. 25 It's a very sensitive subject you cannot tell the patient 'Oh by the way, I think you are obese' because you'll end up offending them, they'll never come to your clinic again [laughs]. GP, Singapore (who ran several private clinics) 25 Clinicians reported softening of terms and generally avoiding the term obesity because of its negative connotations. 51  Difficulty making progress on a complex problem in time constraints Weight and obesity were reported as too complex to deal with in a 10-min appointment, 50 especially if a patient was presenting for another reason. 27,47,34 The complexity of the subject was attributed to the belief that obesity was related to many other aspects of a patient's life 50,46 and that behaviour change was a long-term process requiring long-term management. 42 The personal and societal roots of the issue made clinicians feel disempowered to properly address within the time constrains of their consultations. 46 Comparative difficulty of assessing obesity Some GPs, nurses and GP trainees suggested that obesity was more difficult to discuss than smoking 39 because smoking was seen as a more accepted risk factor 47 and more straightforward to assess 28 and treat. 39 There was a perception that smoking was a clear choice in behaviour whereas obesity was a consequence of a long-term aggregation of several behaviours.
Smoking is more a choice while becoming overweight just happens. GP, New Zealand 46 These behaviours (such as diet and physical activity) were often inferred by appearance, only being assessed if the patient was visibly overweight. 28 Reported mechanisms used to broach the awkward topic A long-term trusting relationship between the patient and clini- Clinicians described linking discussions of weight to relevant medical concerns. 25,30,33,37,40,46,51 The topic was also seen as less interactionally difficult when they positioned the issue as more 'doctorable' (e.g., if there was severe obesity 28,33 and bariatric surgery 48 was a treatment option.
For those seriously overweight … who are either encountering medical problems, or at a high risk of medical problems, and actually probably what we should be taking is a more medical medicalised approach. UK, GP 33 Some GPs and nurses said they felt more comfortable reframing weight loss discussions as recommendations about maintaining health. 30,51 GPs and nurses also speculated that if they were 'forced' to intervene by some mechanism, they would be more likely to discuss weight. 28 3.3.2 | Lack of confidence in treatments and patients' ability to follow treatments, and lack of knowledge and skills Three themes widely developed across studies: a lack of confidence in the treatments (reported in 17 studies), clinicians' lack of knowledge and skills to support weight loss (cited in 15 studies) and lack of confidence in patients' abilities to make changes and sustain weight loss (cited in 17 studies).

Lack of confidence in treatment
Clinicians' lack of confidence in treatment was a key theme addressed in 17 of 29 papers. It covered a number of subthemes described as follows. The lack of confidence in skills was in some instances blamed on lack of a standardised approach to raising the issue. 47 Despite this, some clinicians attempted interventions drawing from personal experience and media sources. 47 Lack of confidence in patients' ability to make changes Clinicians doubted that patients had the ability to make changes with some suggesting that the prevalence of obesity in society was proof that individuals' weight loss strategies did not work. 37 They expressed these thoughts sometimes in pejorative terms.

Lack of previous success
You can lead a horse to water but you cannot stop it eating cream cakes. GP, UK 43 This pessimism was sometimes presented as borne of experience, but some acknowledged their own lack of skills 29 and knowledge of effective treatment, 37 which contributed to a reported feeling of powerlessness. 33 Some GPs said that they wanted to encourage patients to lose weight but did not know how to do so, 29 whilst others spoke pejoratively about patients who were reluctant to change. 46 Lack of confidence in existing guidelines and metrics of success Some GPs believed that following guidelines which encouraged clinicians to use weight metrics and to judge success by weight or BMI 'as yardsticks of success' was the wrong approach. Furthermore, this damaged their self-efficacy since they knew they did not believe what they were being told to recommend and track would help people lose weight.
I do not want to be falsely saying… 'I really believe if you do this this would be effective'… GP Australia 29 Authenticity was also felt more challenging by those clinicians with a lower personal BMI. 51 National guidelines were judged by some as needing to be localised, taking into account local needs and variances in obesity service provision. 43 Others were reluctant to follow national guidelines, 35

Mechanisms to improve clinicians' confidence in prospect of change
Across several studies, clinicians reported that tracking patients' weight had made them less pessimistic. 25,30,33,37,40,46,51 Even where this system was not in place, some GPs reflected that they thought it would help. 29 Gudzune describes clinicians' belief that by acknowledging any degree of weight loss success provided positive reinforcement.
'You've lost six pounds since you were here last.' [Patients] really need that positive feedback that we are paying attention to what they are doing. GP,

Singapore 30
Nurses in a UK study said they found it effective to link weight loss to a future social event in patients' lives (e.g., wedding) to incentivise change. 45 Similarly linking patients' weight to wider objective health measurements was perceived to keep patients motivated. 30 Another approach was to moderate GPs' and nurses' expectations so that modest weight loss, or no weight gain, could be seen as an achievement. This approach of encouraging either moderate weight loss or preventing weight gain was observed to ameliorate GPs' sense of frustration. 11,29

| Responsibility
Another highly developed descriptive theme, reported in 20 studies, was that it was not GPs' and nurses' responsibility to intervene.
These papers discussed subthemes, including the boundaries of medical responsibility, patients' responsibility, differences in role perceptions between GP and nurses and the role of the clinician in society.

Medical responsibility does not include treating obesity unless severe
There was concern about medicalising what many viewed as a nonmedical problem 4

Different responsibility between GPs and nurses
There were differences between nurses and GPs attitudes towards discussing weight. Some GPs suggested that dealing with overweight and obesity was an inappropriate use of their time or that responsibility for this task should be shifted to nurses. 11,40 Both nurses and GPs reported that talking about weight could damage their patient relationship, but nevertheless, nurses reported feeling responsible for raising the topic. 47 No studies reported nurses saying that treating patients with obesity was not their responsibility (0/10), whereas GPs in 11/20 studies did report this.
We are not the friendly neighbour, we are health care professionals. I do see it as my professional task to tell patients about the risks of their weight …. Nurse,

Netherlands 42
Society's responsibility Some GPs believed that their responsibility to intervene was somewhat undermined by a belief that the bigger actions lay with society. 35 Some nurses said that causes of obesity, including childbirth and media influences, were too complex to resolve through a general discussion and therefore focused on patients taking greater personal responsibility. As one author 51  However, if a disease associated with obesity was present, then intervention could be justified as it 'lifted the negativity and ambiguity that existed about managing obesity,' 11 though even in such a scenario, one GP reported that it would still be a task better suited to a nurse. 40 A final mechanism which GPs reported making them feel responsible was having a system of long-term follow up in order to achieve sustained weight loss as this Dutch GP suggests, There is a neat reporting system, but after the last treatment no one feels responsible. 42

| Lack of resources and competition for resources
Doctors and nurses reported that they did not have sufficient time to address overweight 40 and that other activities took priority. 47 That's the trouble is not it, it's the conflict of time for all the other things that we are supposed to do in a ten-minute consultation, of which probably smoking cessation comes quite high on the sort of health promotion thing … and alcohol, of course, that's another.

Nurse, UK 47
Contexts when time and resources were allocated to obesity When there was a formalised framework, GPs and nurses reported feeling a sense of duty to make weight interventions. 4

| Stigma
Stigma was a descriptive theme that was apparent in the tone of many clinicians' responses to statements and cited by many of the primary authors. 27,40,41,43,47,50,51 It can be seen in a number of themes.

Difficulty negotiating the stigma when advocating weight loss
Clinicians reported a worry that patients would think they were stigmatising them by talking about weight and imply they were lazy or greedy, 46 which sometimes led them to avoid the topic. 50 The stigmatised nature of obesity in society more generally made some clinicians avoid the topic even if they themselves did not report a stigmatised attitude towards patients. 36 Other clinicians noted the associated psychological problems with obesity as stigmatising and sometimes assumed they had associated conditions which made con- Others had a stigmatised attitude towards those with obesity, describing patients as lazy and lacking in energy or indifferent to their situation. 40 Even those who were motivated to lose weight were thought to be reluctant to make the necessary changes. And those who did seek help did so for the wrong reasons, such as wanting to wear smaller clothes. This stigmatised attitude towards patients was especially apparent in papers which focused on patients on low incomes 37 or those from certain ethnic backgrounds, 40 with these groups reported to be less frequently counselled.

Contexts when stigma was overcome
Some clinicians believed that the stigma could be overcome by focusing on health-focused approaches rather than purely weight focused approaches. 29 These included the 'Health at Every Size' movement which aims to reduce weight-related stigma by focussing on other potential health-related benefits of interventions, by focusing more on medical endpoints such as fasting glucose or blood pressure, aiming for a maintenance of current weight (over or otherwise) or aiming for lifestyle changes such as increased physical activity which have recognised health benefits independent of weight. 29 Others believed that stigma could be reduced by not using terms such as 'obese' or talking around the topic.
I just talk in terms, you know, 'Have you ever thought, you know, trying to lose weight?' or this sort of thing, not just saying, 'You're obese.' I think that they must know they are overweight-you do not want to rub it in. Nurse, UK 36

| Analytical theme summary
Although the papers reported different clinical perspectives across different settings, there were clear similarities connecting clinicians' views towards discussing weight ( Figure 2). Each of these themes contributed to clinicians affording low priority to intervening with patients on obesity. Clinicians often spoke about patients with obesity in a way that reflected society's underlying stigma about obesity.

| Analytical theme: Low priority of weight discussions
The main overarching theme that binds the first-and second-order themes was the low priority given to obesity interventions. This was remarkably consistent across studies over decades of research.
This sense of low priority was shared by doctors, nurses, doctors in training and across different health-care systems (both public and private).

| Low priority of weight discussions
Many of the descriptive themes listed in Table 1 can be viewed through the lens of priorities (Figure 2). Discussing weight was not a priority for GPs and nurses at all levels of seniority. This higher-order latent theme was present even amongst those GPs and nurses who said they had confidence in their patients and in the treatments. Even those who saw discussing weight as their responsibility often did it reluctantly. 26,40 Prevention activities perceived as a second division of optional approaches … the doctor in general is more concerned with whether the patient smokes or has high cholesterol … Spanish study of GPs and nurses 24

Stigma
Stigma fed into the low-priority theme. In some clinicians' responses, their tone hinted that recipients of their care are unworthy or make themselves unworthy of their time and constructed obesity as an individual behavioural problem. 33 Obesity was constructed by some clinicians as both a fault of individuals' behaviours whilst also noting that it was a social problem for wider society to deal with rather than be medicalised in their clinic 33,34,37,40 (Tables 2 and 3).  35 Ali et al. 38 Ampt et al. 28 Antognoli et al. 27 Ashman et al. 54 Asselin et al. 49 Blackburn et al. 47 Brown et al. 36 Claridge et al. 46 Derksen et al. 42 Douglas et al. 32 Theoretical framework Paper congruity Epstein et al. 33 Glenister et al. 50 Gudzune et al. 30 Gunther et al. 43 Hansson et al. 40 Forman-Hoffman et al. 34 Heintz et al. 41 Huang et al. 31 Jochemsen et al. 39 Kim et al. 48 Leverence et al. 37 Theoretical framework Lee et al. 25 Mercer and Tessier 11 Nolan et al. 26 Phillips et al. 45 Ribera et al. 24 Sonntag et al. 44 Teixeira et al. 4 Theoretical framework

| Findings in relation to the existing literature
We identified four existing reviews in this domain, two of which were either exclusively 58 quantitative or predominantly quantitative studies. 13 Regarding the two remaining qualitative reviews, one 14  Stigma was a theme that was raised in a number of different guises by clinicians in our study, building on a wide body of work on this topic. 59,60 There was an apparent contradiction in clinicians' attitudes who could simultaneously think it was both individual's responsibility to lose weight but also caused by a wider social problems, and both these perceived causes meant that intervening was not worth the clinicians time. This mindset has been previously highlighted in analysis of moral discourse in clinicians accounts about weight counselling, 61 which they noted contributed to a feeling of both tension and powerlessness amongst clinicians. Our study built on this individual versus society analysis and found that this attitude became more acute towards patients from poorer backgrounds, who they deemed lazier, 37 and towards groups from certain ethnic backgrounds, whose cultures did not prioritise weight loss interventions. 46 We also built on existing literature that had highlighted that clinicians may not always stigmatise individuals but find it hard to negotiate stigma when advocating weight loss. 61 Our study also complemented literature 62

| Meaning of the study: Possible mechanisms and implications for GPs, nurses and policymakers
The findings suggest that GPs see intervening on obesity as a low priority. This feeling was not so marked for nurses. The lack of confidence in the patients and treatments sometimes gave the impression that it was not that GPs did not have sufficient time, but treating obesity was not worth their time [1], sometimes related to an underlying stigma towards those with obesity. 50 What little time they did have should be used to treat priorities such as disease and more important prevention activities. 24 It appears therefore that GPs do not want to intervene or do not like intervening, and some of the reasons proffered may mask this underlying sense of dislike.
Why might this be so? Anthropological studies of medical training show the emphasis placed on diseases, technical procedures and technological medicine and less on the behavioural aspects of medicine, such as prevention especially areas such as obesity where there are no easily prescribed medicines. 63,64 GPs in training believe that disciplines of medicine that involve highly technical procedures or experiments, such as surgery or laboratory medicine, are more prestigious than primary care. 65 Normalisation Process Theory proposes that interventions are adopted if clinicians value them. 66 Nursing places less emphasis on the technological aspects, and thus nurses seem to feel more duty to act on what both groups consider to be an important risk factor for ill health. Thus, interventions to support physicians need to grapple with this cultural block and find a way to make clinicians, particularly doctors, feel that intervening on obesity is valuable work. In addition, clinicians were highly sceptical of their ability to intervene for patients and patients' ability to respond, but such beliefs can be countered with evidence, but they also need the skills and confidence to enact brief interventions.
When GPs did decide to intervene, they did so in a way which evidence has shown to be unhelpful. To navigate the perceived interactionally difficult and stigmatised topic, GPs and nurses talked around the issue 50 or linked weight to a corresponding health issue, believing they were on 'safer ground' and this would cause less offence to a patient. 46,50,67 However, there is evidence that GPs' and nurses' attempts to link discussions of weight to the patients' own health issues can result in resistance. 56 Other previous studies have noted the interactional delicacy and suggested that training is needed to make clinicians far more confident in navigating this delicacy. 68

| Summary and future perspectives
Clinicians offer a variety of explanations as to why they do not offer support to their patients to lose weight, despite national guidelines that urge them to do so. These relate to the awkward and potentially stigmatising nature of the conversation, the lack of faith that patients will change and their own lack of a clear intervention to offer.
However, underlying all this is a sense that such conversations are not valued, especially by doctors, and that this relates to unspoken value systems in medicine that prize technological fixes over behavioural interventions. Addressing nonadherence with guidelines will require attention to these underlying values.

When GPs and nurses allocate their time and resources
to dealing with obesity.
• When weight measurement becomes mandatory.
• When there is a formalised template/framework.
• Reported mechanisms to address GPs' and nurses' perceived feeling of lack of responsibility.
Create a system of permanent follow-up.
Raising awareness about obesity associated diseases.
Emphasise how interventions are part of a broader societal effort to tackle the multiple and complex causes of obesity.
• Reported mechanisms to improve GPs' and nurses' confidence in patients and treatments: Linking weight loss to an upcoming event; Seeking wider objective health changes, like blood pressure, to keep patients motivated; Having a system of follow up.
Moderate GPs' and nurses' expectations to seek only modest weight loss or no weight gain.
• Reported contexts and mechanisms to make discussing weight less interactionally difficult: Using computer prompts.
Routinely recording the patients' BMI.
Linking the patient's weight to comorbidities and medicalizable conditions.* Having a long-term trusting relationship.
When there is severe obesity and the issue becomes more doctorable, particularly if bariatric surgery is a treatment option.
Referring to broader 'health' changes rather than 'weight' changes.